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* Fungal meningitis deaths rise to 20, total cases up to 254
* Patients need to be diagnosed, treated early
* Senator seeks information on Defense Dept pharmacy contract (Adds NECC statement, paragraph 8)
By Bill Berkrot and Deena Beasley
NEW YORK/LOS ANGELES, Oct 18 (Reuters) - U.S. health officials made their first confirmation of the presence of a deadly fungus in one of three lots of steroids tied to a national meningitis outbreak as the death toll rose to 20 on Thursday.
The U.S. Food and Drug Administration said it was still testing two additional lots of methylprednisolone acetate, the steroid used to treat back pain, for the presence of the rare Exserohilum fungus. It is also testing other injectable drugs that were supplied by the New England Compounding Center (NECC) in Massachusetts.
"Now we can definitively say that the injections are linked to the infection," Dr Tom Chiller, an epidemiologist with the Centers for Disease Control and Prevention, told Reuters in an interview. "To date, CDC has no firm evidence of infection in any patients beyond those exposed to the contaminated lots."
CDC said the death toll climbed by one to 20, while nine new cases brought the national total to 254, including the first in New York - the 16th state with confirmed infections.
Michigan reported its fourth fungal meningitis death and new cases were also reported in Indiana, New Hampshire, New Jersey, Ohio and Tennessee. There are also three cases of peripheral infections in joints, the CDC said.
"There were a lot more spinal injections performed versus joint injections, but the infection rate may also reflect the fact that joint infections might be slower or the incubation period could be longer ... we just don't know," Chiller said.
About 14,000 patients are believed to have been exposed to the potentially tainted NECC steroid and some 97 percent of them have been contacted so far, the FDA and CDC said.
NECC issued a statement saying it is "earnestly focused on determining, along with these agencies, the cause of contamination in vials of this product - and to rapidly and professionally carry out a recall to remove all NECC products from circulation."
U.S. doctors in Baltimore said early diagnosis and treatment of patients at risk of fungal meningitis is vital, based on the case of an otherwise healthy woman who declined rapidly after receiving steroid injections for neck pain.
Writing in the Annals of Internal Medicine, researchers at the Johns Hopkins School of Medicine described the deterioration of an unnamed 51-year-old who sought care in an emergency room for a severe headache a week after receiving an injection with tainted medication on Aug. 31.
The CDC has said it learned about the fungal meningitis outbreak on Sept. 21 and that it has contacted patients injected as far back as May.
NECC is under investigation by federal authorities over how it supplied hospitals, clinics and other healthcare providers with large orders of compounded drugs, including whether it violated state laws regulating pharmacies.
U.S. Sen. Richard Blumenthal Of Connecticut, who previously called for a criminal investigation of NECC, on Thursday raised new questions about a government contract for medications from NECC's sister company, Ameridose.
In a letter to the U.S. Department of Defense, he cited a July purchase agreement for specialized medicines between the U.S. Army Medical Command and Ameridose. They were intended for use in the neonatal intensive care unit at the Army's Tripler Medical Center in Honolulu.
"I am deeply concerned that this contract exposed numerous military families to a drug produced by a compounding center that was unregistered with the FDA and uninspected for safety and effectiveness," Blumenthal's letter said.
Most of the meningitis cases have been linked to Exserohilum, a fungus associated with grass and rotting wood that appears to be especially aggressive in attacking tissues in the spine and brain stem.
Fungal infections typically only attack people with severely compromised immune systems, such as patients who have had bone marrow or organ transplants.
In the case described by the team at Johns Hopkins, the injection was the woman's first and she had no medical history of having a compromised immune system, nor was she taking any long-term medications.
Doctors found nothing and sent her home, but the woman returned the next day with more severe symptoms and was admitted to the hospital, where she was treated with a series of antibiotics and other drugs.
Tests for a host of infections were all negative. The woman died 10 days after being admitted to hospital, the same day the team found evidence of Exserohilum in her spinal fluid. An autopsy showed massive tissue death in the brain stem, inflammation in the blood vessels and evidence of a stroke.
Based on the case, the researchers urged doctors to be aware of the symptoms of fungal meningitis and to seek rapid diagnosis and treatment to prevent "serious complications and deaths."
The CDC advises patients who feel ill and are concerned they were injected with one of the recalled products to contact their physician.
On a call with healthcare providers earlier this week, the CDC said the typical incubation period was one to four weeks after injection, but that it could be two months or longer.
"We want you to remain vigilant for several months after injection," Chiller told physicians.
Symptoms of fungal meningitis include new or worsening headache, fever, sensitivity to light, stiff neck, weakness or numbness in any part of the body, slurred speech, increased pain, redness or swelling at the injection site. (Additional reporting by David Bailey in Minneapolis, Julie Steenhuysen in Chicago and David Morgan in Washington; editing by Michele Gershberg and Matthew Lewis)